Endometrial Ablation

Early Discharge after Hysterectomy for Benign Diseases by Mini-Laparotomy

Author: S. N. M. Youssif

Is a procedure that aims to destroy or remove the lining of the uterus / womb, to reduce or stop menstrual bleeding / periods.

To suppress menstrual bleeding effectively, it is necessary to remove the full thickness of the endometrial lining as well as the superficial muscle layer (myometrium).

Endometrial ablation techniques can be used in women with menorrhagia in whom medical therapy causes intolerable side-effects or is contraindicated.

Endometrial ablation offers an alternative to hysterectomy, enabling preservation of the uterus.

You may need endometrial ablation if:

You use more than nine pads or tampons (or both pads and tampons) on your heaviest days
You have to wear both a tampon and a pad
Your period lasts more than six days
You have to get up at night to change your protection
You pass blood clots
You stain your bedding or clothes despite wearing tampons and pads
You have period flooding
You stay at home or take time off work during your period
Endometrial ablation methods are termed first-generation or second-generation.

First generation techniques include

Transcervical resection of the endometrium with an electrosurgical loop (TCRE)

Rollerball endometrial ablation (RB)

TCRE/RB Combined

Neodymium:yttriumaluminium garnet laser endometrial ablation (Nd:YAG)

All the above use a hysteroscope and fluid medium, and require a high level of technical skill.

Second-generation techniques include

Microwave endometrial ablation (MEA)

Fluid Filled Thermal balloon endometrial ablation (TBEA)

Radiofrequency electrosurgery

Hydrothermal ablation

Cryoablation

Endometrial thermal intrauterine thermotherapy

Second-generation EA techniques also include

Radiofrequency (thermoregulated) balloon EA,

Diode laser hyperthermy, and

Photodynamic therapy.

All the above are newer techniques which are usually do not require use of hysteroscope, do not require a fluid medium and require less training to perform.

The newer techniques may be safer. For example the risk of bleeding may be lower, even though the surgeon can’t see what is happening in the womb during the operation.

Criteria that should be noted before considering endometrial ablation (first and second generation);

There are no cancerous or precancerous lesions of the endometrium or cervix
Completion of childbearing
No acute genital tract infection
Uterine size less than the equivalent of 12 weeks gestation or uterine cavity length less than 12 cm
No fibroids greater than 5 cm in diameter
No absolute desire for cessation of periods (amenorrhoea)
Adenomyosis (endometriosis in uterine muscles) may limit the effectiveness of endometrial ablation and may be a relative contraindication
Repeated anovulation may limit the effectiveness of endometrial ablation procedures and may be relative contraindications.
Resection of uterine submucous fibroids ( <5 cm ) should be considered prior to endometrial ablation.

Success of endometrial ablation is less likely in women with a large uterus or if there is uterine myomas or adenomyosis.

How can this operation help me?

Periods are lighter for around 8 in 10 women who have their womb lining removed.

Periods stop completely for over a third of women.

Nearly three-quarters of women are satisfied after endometrial ablation using diathermy.

In one study, 8 in 10 women said they would recommend the treatment to their best friend.

After rollerball ablation to remove their womb lining, women in one study said they had improvements in

Pelvic pain (pain in the tummy and back): Nearly three-quarters of the women said they had less pain
Premenstrual symptoms: Over two-thirds of the women had fewer symptoms, such as bloating and feeling irritable, before their period
Their sex life: Almost all the women said their sex life got better after the operation
Ability to do usual activities: All women could return to normal work and 8 in 10 found housework easier

But endometrial ablation doesn’t work for everyone. Up to a quarter of women who have this operation still have heavy periods. The operation seems to work less well in women under 40.

What are the risks of Endometrial Ablation?

All operations have risks but serious problems seem to be rare with endometrial ablation.

Your gynaecologist should tell you about the risks with this operation before you have it. It’s important to tell the doctor if you have any allergies.

Anaesthia can have side effects. For example, you may feel sick afterwards. It is also possible, but rare, to have an allergic reaction to the anaesthetic. Your blood pressure, heartbeat, body temperature and breathing will be closely monitored during the operation.

Complications or Problems that can happen during or immediately after surgery

One in 30 women had complications from endometrial ablation

Perforation of the womb or tear of cervix: The heated instrument may burn or pierce through the womb.
Very heavy bleeding may occur during the operation as in transcervical resection of the endometrium with an electrosurgical loop or afterwards.
Infection can occur and antibiotics are used for treatment.
Absorbing a litre and a half of fluid into your bloodstream. The gynaecologist will stop the operation because this can make you ill.
Injury to the bowel: The bowel is close to the womb and can stick to it. So it may be burned by the heated instrument in the womb.

About 1 in 100 women need emergency surgery during their operation to correct a problem. About half of these operations are to remove the womb (a hysterectomy). Others need to have a hole in their womb repaired.

Complications or Problems that can happen well after surgery

Heavy periods can come back. About 1 in 4 women need another operation within five years of having their womb lining removed because the lining has regrown and their periods have become heavy again.

If this happens, you can have the same type of operation or a hysterectomy. More than 1 in 10 women have a hysterectomy within two years of having endometrial ablation.

If you’ve been sterilised before you have rollerball ablation, you’re more likely to suffer pain in your pelvis and need a hysterectomy. This is known as postablation tubal sterilisation syndrome. Between 1 in 10 and 1 in 20 women who have rollerball ablation after being sterilised have this problem.

Using a rollerball to remove the womb lining may cause fewer problems than using a heated wire loop (transcervical endometrial resection). For example, the chances that the gynaecologist will damage blood vessels are slightly smaller with rollerball ablation, so you’re less likely to bleed heavily during the operation. A study involving over 10,000 women found that using the two techniques together was safer than surgery using the heated wire loop on its own. The same study found that 2 out of the 10,000 women died because of transcervical resection of the endometrium with an electrosurgical loop.

What can I expect after Endometrial Ablation?

It takes a few hours to recover after a general anaesthetic, but you should be able to go home the same day. People rarely have to stay in hospital overnight for this type of operation. For the rest of the day you’ll need to stay at home and take it easy.

You may have some cramps (like bad period pains) but these should be gone by the next day. Painkillers, such as ibuprofen or paracetamol, should help.

Your doctor may also give you antibiotics to stop you getting an infection.

You will get a watery discharge for about 10 to 14 days. This discharge may be a bit blood-stained at first.

You should be able to drive the next day and be back at work within two or three days.

You might want to wait to have sex until the watery discharge has stopped.

If you are having hormone replacement therapy, you can continue to take it after this operation.

There will be some scarring inside your womb, but you’ll only be able to see it on a scan. The electrical current used in this operation is set at a low level so it can’t burn any deeper than 6 millimetres. This stops the wall of the womb being damaged.

Can I get Pregnant after Endometrial Ablation

It’s harder to get pregnant after your womb lining has been taken out, but it is possible. You should use your normal contraception unless you’ve had an X-ray to confirm that you’re no longer able to have a baby. Some women find that their periods stop altogether after this operation.